which action by the novice nurse indicates a need for further teaching
Logo

Nursing Elites

NCLEX-PN

Nclex 2024 Questions

1. Which action by the novice nurse indicates a need for further teaching?

Correct answer: A

Rationale: The correct answer is A. The novice nurse failing to wear gloves when removing a dressing indicates a need for further teaching to emphasize infection control practices. This action can lead to the spread of infections. Choices B, C, and D are incorrect because they demonstrate proper nursing skills and techniques. Applying an oxygen saturation monitor to the earlobe, elevating the head of the bed to check blood pressure, and placing the extremity in a dependent position to acquire a peripheral blood sample all reflect understanding of correct procedures in patient care.

2. A client recently lost a child due to poisoning. The client tells the nurse, 'I don’t want to make any new friends right now.' This is an example of which of the following indicators of stress?

Correct answer: C

Rationale: The correct answer is C, 'sociocultural indicator.' This client's reluctance to make new friends after experiencing a traumatic event like losing a child is a clear sign of sociocultural stress. Sociocultural stress can impact a person's social interactions, relationships, and cultural practices. Choices A, B, and D are incorrect. Choice A, 'emotional indicator,' would focus on emotional responses directly related to stress. Choice B, 'spiritual indicator,' refers to stress related to spiritual beliefs, practices, or values, which is not evident in this scenario. Choice D, 'intellectual indicator,' is not a recognized category of stress indicators in this context.

3. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?

Correct answer: C

Rationale: The most crucial assessment during the preoperative period for a client with a sacular abdominal aortic aneurysm scheduled for surgical repair is the identification of peripheral pulses. During surgery, the aorta will be clamped, potentially affecting blood circulation to the kidneys and lower extremities. Therefore, it is essential for the nurse to assess peripheral pulses and monitor the return of circulation to the lower extremities postoperatively. Assessing the client's level of anxiety (Choice A) is important but not as crucial as ensuring adequate circulation. Evaluating exercise tolerance (Choice B) is not recommended preoperatively for this situation. Assessing bowel sounds and activity (Choice D) is of lesser concern compared to the critical need to monitor peripheral circulation.

4. The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?

Correct answer: B

Rationale: A persistent cough might be related to an adverse reaction to captopril (Capoten). Tinnitus (choice A) and diarrhea (choice D) are not commonly associated adverse reactions of captopril. Muscle weakness (choice C) might occur initially but is not considered a common adverse effect of captopril. Therefore, the correct answer is B, persistent cough, as it is a known adverse reaction to captopril.

5. When assessing a client in crisis, what should the nurse prioritize?

Correct answer: C

Rationale: When a client is in crisis, the nurse's priority is to focus on immediate stress reduction. Crisis intervention aims to stabilize the client in the present moment by addressing the most pressing issues. Allowing the client to work through independent problem-solving (Choice A) may not be appropriate during a crisis as they might need immediate support. Completing an in-depth evaluation of stressors (Choice B) is important but not the immediate priority during a crisis. Recommending ongoing therapy (Choice D) may be considered later, but the immediate focus should be on reducing the client's stress and stabilizing the situation.

Similar Questions

Which of the following attitudes is essential in a nurse who assists clients during crises?
A 5-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?
James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as:
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
When teaching clients with a diagnosis of Schizophrenia nearing discharge from a residential care facility, what is an essential topic to include?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses